Richard Caesar Surgery

FillersSecond only to botox, fillers are the mainstay of non-surgical aesthetic treatments. They are an extremely effective way of adding volume to deeper layers and hydration to superficial layers of your skin.Modern hyalan fillers are safe and controllable. The wear off slowly, but should you not like the effect they can also be dissolved by an injection of hyaluronidase. The most popular areas are the lips, corners of the mouth, nasolabial lines, cheeks, tear trough and lateral brow.As the fillers need to be injected there is some discomfort. This can be reduced with local anaesthetic. Occasionally there can be some bruising. The majority of my patients seem to prefer no local anaesthetic at all for all areas other than the lips. They find the numb sensation more unpleasant than the stinging of the injection. After the injection the area is usually red and swells a little for the first few days, before settling down.The effects are immediate and last from 6 to 9 months for the thinner fillers and up to 2 years for the thicker fillers. It is important however to use the right filler in each location, as too thin too deep is poor value, and too thick too superficial is a lump that will need dissolving!So which filler is best?I'm personally not going to use any filler that I can't dissolve. There may be longer lasting results with Sculptra and Radiesse, but the fact that I couldn't remove any excess filler tips the results for me. I therefore only use the hyaluronic acid fillers, and if I'm really honest I'm not sure I can tell them apart. The QMed range are excellent, as is the Teosyal range. Belotero seems good, and I've no problem with Juvederm. They are all similarly priced, and I think can all be used very successfully.The key is to use the right thickness filler for the depth and effect you want to achieve.How to price fillers?I charge full price for the first syringe and subsequent syringes are less. I do not like the overfilled look and would rather put in too little filler than too much. I therefore offer all my patients the option of returning after two weeks for extra filler at the second syringe price. This ensures there is no financial cost of using less filler.If I have placed the filler too superficially and given you a lump I will dissolve the filler and refund your costs, or dissolve and re-inject for free two weeks later. This should be the standard of care from all clinics.

Cheek and Tear Trough FillerAs we age one of the effects is the downward sag of the midface. This results in the lateral extension of the tear trough until it effectively turns the youthful curve of the cheek into two curves, the lower of these curves extends into the nasolabial lines and into the jowl on the jawline. A facelift is an effective approach to the jowl, but doesn't replace the missing volume. A better solution is therefore to replace the missing volume, hence the popularity of deep cheek filler.This is particularly effective on its own in your 40s and 50s, and can be added to a facelift in your late 50s and 60s. I use the more viscous long acting hyaluranic fillers as they are effective, reasonably long lasting and crucially reversible. The technique is shown below. There has been debate as to how much filler is required. I like the less is more approach, and will put as little as 0.6ml in each side in the first instance, especially in a younger patient. If your cheeks are flat then you will normally need a syringe each side.If you are considering tear trough filler always appraise your cheeks first, as cheek filler is a more effective approach to the lower part of the tear trough. I recommend doing the cheeks first, as you can then better judge how much filler you need for the tear trough.

Tear Trough FillersA classic complaint for many is that of dark circles under the eyes. This is phenomenally difficult to correct surgically. One of the most effective techniques is to use filler to plump up the tear trough. The results are immediate and last from 6 to 9 months.This is an advanced treatment with fillers and there have been variable results. The secret is to use a thick but not too thick filler, and to make absolutely sure that all the filler is injected deep to the orbicularis muscle directly on the bone. This can be slightly unnerving for the patient, as the tip of the needle needs to tap against the bone. The pressure on the plunger also needs to be released for some seconds before the needle is withdrawn to allow the build up of pressure in the barrel of the syringe to ease. If this is not done a trickle of filler comes out anterior to the muscle and can give a small lump. In my opinion less is more and I would recommend using only half a syringe each side initially. You can always top up after two weeks.The skin is very thin in this area so bruising is more common and more visible, but will wear off over a few days and can always be hidden with foundation.As ever with the hyalan fillers - if you do not like the result the filler can be reversed with hyaluronidase.

What can go wrong with fillers?1. Bruise at the injection point2. Overfilling. The aesthetic effect of fillers requires judgement. If you put too much in it can simply look wrong. Make sure you discuss exactly the effect you want. The hyalan fillers can be dissolved if overfilled.3. Lumps. The effect can be lumpy if the filler does not spread as desired, or if there is a local area of overfilling. There is a trade off between the thinner fillers which are less likely to create lumps but do not last as long and the thicker fillers that can be more lumpy but last longer. Lumps can be dissolved with tiny amounts of Hyaluronidase but the risk is that the main body of the filler is also dissolved.4. Allergy. The risk is very low but possible. All practitioners should carry treatment for an acute allergic attack.5. Inadequate result. This is easy to resolve with additional filler6. Injection into a blood vessel causing an ulcer to the skin supplied by that blood vessel. This catastrophe must be avoided by knowledge of the anatomy and careful injection. 7. Blindness has been reported with fillers entering blood vessels that supply the retina. This is very rare.8. Infection of the filler that then does not respond to antibiotics has been reported, such that surgical removal is required. This is very rare.